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illumination. Fiberoptic
light transmission provides a 360 ring of light without visual
obstruction or specular reflection. This distal light results in
glare-free viewing and an easier examination.
Focusing capability (MacroView Otoscope Only)
The Welch Allyn MacroView otoscope has the capability to zoom
in or out on the area in view, resulting in a clearer image to aid
in diagnosis. A focusing wheel, conveniently located on each
side of the otoscope and the back eyepiece, is available to the
practitioner for adjusting the focal length. The adjustable focal
length can compensate for both the practitioners vision and
the length of the patients ear canal, thus creating the clearest
view of the tympanic membrane possible.
Pneumatic otoscopy capability
When examining tympanic membrane mobility, the
ability to perform pneumatic otoscopy is extremely
valuable. The Welch Allyn otoscope incorporates
a closed system and an airtight seal.
Specula attachment and removal
The Welch Allyn MacroView otoscope features
a unique specula attachment and removal design,
the TipGrip, which provides the practitioner with a
secure attachment between the specula and the otoscope during the exam.
After the examination is complete, the tip can be released from the otoscope
by turning the TipGrip counterclockwise or by simply twisting off the tip
with one hand, as is the technique with traditional otoscope models.
SPECULUM OPTIONS
In order to obtain the maximum field of view, the examiner should
always select the largest size speculum which fits comfortably into the
patients ear canal.
The following guidelines may be helpful:
The examiner can choose from several types of specula and
specula accessories:
The first type of speculum is reusable and made of lightweight, durable
polypropylene. Reusable specula are available in four sizes: 2.5 mm,
3 mm, 4 mm and 5 mm.
The second type of speculum is the Universal KleenSpec
, a disposable,
economical and convenient tip. KleenSpec tips are made of nontoxic
plastic and are available in two sizes: 2.75 mm (pediatric) and
4.25 mm (adult).
The third type of speculum, available for traditional Welch Allyn
otoscopes, is SofSpec.,
KLEENSPEC
REUSABLE
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How to Conduct an Otoscopic Examination
1. Carefully inspect the pinna and postauricular skin. Gently palpate the pinna to
determine if any tenderness exists.
2. Inspect the entrance to the ear canal for debris or pus, which might interfere
with further examination.
3. Choose the largest speculum that can comfortably be inserted into the ear
canal. Straightening the outer ear canal makes insertion of the speculum easier.
For adults, this is accomplished by retracting the pinna upwards and backwards.
For children, this is accomplished by retracting the pinna horizontally backwards.
4. When using the MacroView
TM
otoscope, set the focusing wheel of the otoscope
to the default position by aligning the green line on the focusing wheel with the
corresponding green dot on the side of the instrument. You will feel the focusing
wheel settle into the default setting. The majority of the exams can be completed
at the default focusing position.
5. There are two common ways to hold the otoscope. The first way is
to hold the otoscope like a hammer by gripping the top of the power
handle between your thumb and forefinger, close to the light source. You
can conveniently hold the bulb of the pneumatic attachment between the
palm of the same hand and the power handle. It is recommended that
you extend the middle and ring finger outward so they come into contact
with the persons cheek. This way, any sudden flinch by the patient will
not cause the otoscope to be jammed into the ear canal.
The otoscope can also be held like a pencil, between the thumb and the
forefinger, with the ulnar aspect of the hand resting firmly but gently
against the patients cheek. You can hold the bulb of the pneumatic
attachment in the palm of the same hand. If the patient turns or moves,
the otoscope will move in unison with the patients head. This will avoid
possible injury to the ear canal or even the tympanic membrane.
It is very important that the otoscope be held correctly, particularly
when examining children. A sudden movement by the patient could
cause the skin on the inside of the ear canal to be pierced by the end
of the speculum.
6. It may be necessary to adjust the line of sight and the position of the
speculum to get a complete view of the entire ear canal and all areas of
the tympanic membrane. This yields a composite view of the external
canal and the tympanic membrane.
7. If the tympanic membrane or desired area in view is not in focus, the
practitioner has the option to adjust the focal length of the optics system
of the MacroView otoscope. To adjust the focal length, place a finger on
either side of the focusing wheel or on the back eyepiece of the otoscope.
To shorten the focal length or zoom in, rotate the focusing wheel towards
the smaller dashes on the side of the otoscope. To increase the focal length
or zoom out, rotate the focusing wheel towards the longer dashes.
8. After the examination is complete, the used specula should be
removed from the otoscope. Simply twist the specula off or use the
TipGrip feature (MacroView only) by rotating the TipGrip counter-
clockwise to disengage the specula.
25 24
Pneumatic Otoscopy
Pneumatic otoscopy provides practitioners with a simple method for
determining tympanic mobility and helps then recognize many middle
ear disorders.
It is the pneumatic capability and insufflator attach-
ment of the otoscope which enable the examiner to
assess the mobility of the intact tympanic membrane.
This first requires that you use a speculum sufficiently
large to fit snugly into the ear canal in order to
establish an airtight chamber between the canal
and the interior of the otoscope head.
Gently squeezing the insufflator attachment produces small changes
in the air pressure of the canal. By observing the relative movements
of the tympanic membrane in response to the induced changes in
pressure, the practitioner can obtain valuable diagnostic information
about the mobility of the tympanic membrane. When fluid is present
in the middle ear, for example, movement of the tympanic membrane
is generally diminished or absent. The pneumatic otoscope may
also be useful in distinguishing between a thin atrophic intact
tympanic membrane adherent to the medial wall of the middle
ear, which can be made to move, and a large perforation, which
will not move. This procedure provides a simple method for
determining tympanic membrane mobility and is of value in
the recognition of many middle ear disorders.
Common Pathologies of the Ear
NORMAL TYMPANIC MEMBRANE (LEFT EAR)
The normal tympanic membrane (TM) is a pale, gray, ovoid
semitransparent membrane situated obliquely at the end of the
bony external auditory canal. The handle of the malleus is seen
extending downwards and backwards, ending at the apex of the
triangular cone of reflected light. The long process of the incus
and its articulation with the head of the stapes may frequently be
seen through the postero-superior quadrant of a thin tympanic
membrane. The mobility of an intact TM can readily be assessed
by using the pneumatic attachment to the otoscope.
RED REFLEX (RIGHT EAR)
The introduction of a speculum into the external auditory canal
may cause a reflex dilatation of the circumferential and manubrial
blood vessels supplying the tympanic membrane.
Following a prolonged examination of the ear or in a crying child,
this vasodilatation may produce an appearance mimicking that of
an early acute otitis media.
EXOSTOSIS (LEFT EAR)
Exostoses appear as discreet, hard, round or oval outcroppings
which are sometimes pedunculated. Exostoses in the ear canal are
more often multiple than single and are usually bilateral. They are
usually asymptomatic, extremely slow growing and seldom enlarge
sufficiently to occlude the meatus. Multiple exostoses appear to
result from the prolonged stimulation of the bony external canal
with cold water and are consequently seen more commonly in
persons who swim frequently.
27 26
Common Pathologies of the Ear
FOREIGN BODY
A varied selection of foreign bodies has been discovered in the ear
canals of children. In this case, a large piece of sponge rubber was
removed. In adults, a forgotten piece of cotton wool is frequently
found. The foreign body or an unsuccessful attempt to remove
it can both product secondary otitis externa or damage to the
tympanic membrane and ossicles. In young children, it is sometimes
safer to administer a short, general anesthetic.
ACUTE OTITIS EXTERNA (LEFT EAR)
Trauma (fingernails, bobby pins, cotton tipped swabs) and moisture
(after showering or swimming) are the most common factors
responsible for the development of acute diffuse otitis externa.
The skin of the ear canal is painful, infected and swollen, and it
may be impossible to visualize the tympanic membrane. There is
often a considerable amount of keratin debris in the canal which
must be removed if local treatment is to be effective. Gramnegative
and anaerobic bacteria are the most common pathogens; however,
a culture of material should be a clinical consideration.
KERATOSIS OBTURANS
In this condition of unknown etiology, the bony meatus is
totally occluded by a stony, hard plug of whitish keratin debris.
Keratosis obturans is more frequently seen in patients with
bronchiectasis and chronic sinusitis. Removal of this material is
extremely difficult because of its consistency and its frequent
adherence to the underlying canal skin; a general anesthetic
may be required in some patients.
OTOMYCOSIS
Otoscopic examination in cases of otomycosis reveals a white or
cream colored, thickish debris which may have a fluffy appear-
ance due to the presence of tiny mycelia. When the infection is
caused by Aspergillus niger, it may be possible to identify the tiny
grayish-black conidiophores. The underlying external canal skin
is often inflamed and granular from invasion by fungal mycelia.
Otomycosis may follow the use of topical antibiotic ear drops.
ACUTE OTITIS MEDIA
This acute infection of the middle ear cleft frequently intensifies
upper respiratory tract infections and occurs more commonly
in children. In the early stages of acute otitis media, the tympanic
membrane varies according to the stage of the disease. The
tympanic membrane is retracted and pink with dilatation of the
manubrial and circumferential vessels. Later, as the disease pro-
gresses, the tympanic membrane bulges, becoming fiery red
in color and may eventually perforate, releasing pus into the
external auditory canal.
SEROUS OTITIS MEDIA (RIGHT EAR)
In serous otitis media the tympanic membrane is retracted and
shows decreased mobility with pneumatic otoscopy. The handle
of the malleus is usually foreshortened, chalky-white in color, and
the lateral process is prominent. The presence of a thin, serous
effusion within the middle ear gives the tympanic membrane a
yellowish or even bluish appearance, and in cases of incomplete
eustachian tube obstruction, air bubbles or an air fluid level may
be seen.
29 28
Common Pathologies of the Ear
TYMPANOSTOMY TUBE (RIGHT EAR)
A tympanostomy tube is often inserted into the tympanic
membrane to ventilate the middle ear in cases of chronic serous
otitis media. These tubes come in a variety of sizes, shapes and
materials. The tympanostomy tube should be seen to be in place
in the tympanic membrane with its lumen patent and free of any
exudate or debris.
CENTRAL PERFORATION OF THE
TYMPANIC MEMBRANE (LEFT EAR)
Perforations of the pars tensa of the tympanic membrane can
result from infection or trauma. In this case the large central
perforation resulted from repeated middle ear infections.
HEALED CENTRAL PERFORATION
(RIGHT EAR)
When a large perforation heals, the middle fibrous layer of
the tympanic membrane remains deficient so that a thin semi-
transparent pseudomembrane resembling an open perforation
may be seen. Gentle use of the pneumatic otoscope will, however,
demonstrate that the drum is intact. This thinned segment of a
healed tympanic membrane lacks the strength of a normal drum
and forceful syringing may result in reperforation.
CHRONIC SUPPURATIVE OTITIS MEDIA
(LEFT EAR)
Chronic suppurative otitis media is characterized by recurrent
painless otorrhea. The discharge may vary from mucoid to
frankly purulent. Pseudomonas, Proteus, and Coliforms are
the three most commonly isolated bacteria; however, fungal
organisms can also coexist.
TYMPANOSCLEROSIS (RIGHT EAR)
Tympanosclerotic plaques of varying sizes are seen as chalky
white deposits in the tympanic membrane. They occur as a
result of a postinflammatory deposition of thickened hyalinized
collagen fibrils in the middle fibrous layer of the tympanic
membrane and indicate that the patient has had a previous
significant ear infection.
TYMPANOSCLEROSIS INVOLVING
THE OSSICLES (LEFT EAR)
Tympanosclerotic plaques may also occur within the middle
ear cavity. This photograph shows tympanosclerotic deposits
enveloping the incudostapedial joint. A few plaques are also
present on the promontory. Partial or total fixation of the
ossicular chain by tympanosclerosis is responsible for some
cases of acquired conductive hearing loss.
31 30
Common Pathologies of the Ear
ADHESIVE (ATROPHIC) OTITIS MEDIA
(LEFT EAR)
Following long-standing eustachian tube obstruction, the tympanic
membrane may become atrophic and retracted onto the medial
wall of the middle ear and ossicles, thereby obliterating the middle
ear space. In this case, a thin atrophic tympanic membrane
is draped over the head of the stapes and the tip of the long
process of the incus has been eroded. It can sometimes be
difficult to differentiate an atrophic, immobile, retracted tympanic
membrane from a large central perforation. In this circumstance,
pneumatic otoscopy is often of value.
TRAUMATIC PERFORATION (LEFT EAR)
These perforations result from a variety of causes, including
a blow to the ear, blast injury, or the insertion of a cotton tipped
swab or bobby pin, but rarely follow forceful syringing. Traumatic
perforations generally involve the posterior part of the pars
tensa. While traumatic perforations may be of any shape or
size, they are usually small with clean-cut edges. Fresh blood
may be seen in the deep meatus. Most traumatic perforations
heal spontaneously, provided the ear canal is kept clean and
dry to prevent secondary infection.
CHOLESTEATOMA (RIGHT EAR)
A cholesteatoma is a slowly expanding and eroding cyst lined
with stratified squamous keratinizing epithelium which invades
the middle ear cleft. The presence of whitish keratin debris
within a postero-superior perforation indicates the presence of
an underlying epidermoid cholesteatoma. Serious intracranial
complications may result from the expansion and erosion of the
cholesteatoma sac.
Other Ear Care Products
EXTERNAL EAR: EAR CANAL
Ear Wash System
Some patients suffer from a build-up of cerumen in the ear canal, which can result in
reduced hearing and prevent the examiner from viewing the tympanic membrane. Ear
washing is a proven method to remove cerumen, and is one of the most commonly
performed procedures in the primary care office. The Welch Allyn Ear Wash System
provides an effective device using suction and irrigation to remove cerumen from
patients of all ages. This easy-to-use system allows for cleaner and safer irrigation
compared to other methods.
MIDDLE EAR: TYMPANOMETRY
A tympanometer provides the most accurate, objective means of determining
middle ear status. Tympanometric results can indicate otitis media with effusion,
perforated tympanic membrane, patent tympanostomy tube, ossicular disruption,
tympanosclerosis, cholesteatoma, as well as other middle ear disorders.
Welch Allyn MicroTymp